1. Thesis for licentiate degree
District nurses’ experiences of wound
management in primary healthcare
-organization and learning-
Karolinska Institutet
E-post:anne.friman@ki.se, telefon:+468-52483694
Alfred nobels allé 23, SE-141 83 Huddinge
Department of Neurobiology Care Sciences and Society
Division of Nursing
Division of Nursing

2. Background
• In Sweden, most patients with wounds are treated within the primary
health care system by District nurses (DNs), both acute and chronic
wounds
• Most patients with wounds are elderly and many of them have a long
anamnesis with a prolonged healing period and relapses
• Studies have found that some patients are treated incorrectly; in regard to
local wound care and aspects related to hygiene
• In many cases, there is no medical diagnosis as basis for treatment
• Although clinical guidelines have been formulated; the treatment of
patients with leg and foot ulcers are not always in accordance with this
information and standards of care

3. Aim and methods
• The overall aim of the thesis were to deepen
the knowledge of wound management in
primary healthcare from DNs' perspective
• The thesis includes one pilot study (I) and two
qualitative studies (II, III)

4. Research focus
Study I investigates the DNs' wound management, including wound
appearance, assignment of responsibility for diagnosis and
care, guidelines for wound treatment and co-operation with
other professional groups
Study II describes DNs' experiences of nursing actions when treating
patients with different types of wound
Study III describes DNs' experiences of knowledge development in
wound management when treating patients with different
types of wounds

5. Methods
• The method for sub-study I was survey consisting of wound registration
form and the questionnaire, and was carried out in five primary healthcare
centres, situated in central Stockholm, and two of its suburbs. The DNs
were asked to complete the survey during one specific week Monday
through Friday
• The method for sub-studies II and III was qualitative interview to gain
deeper knowledge and understanding of the DNs' wound management
• In both interviews (II, III) the interviewer used an interview guide with
topics for support. DNs had varying professional experience and eight of
DNs had special training in wound care

6. Results, Study I:
• DNs treated 283 patients with a total of 310 wounds
• Pressure ulcers (18.1%) and venous leg ulcers (15.8%) were the most
common of the slow healing wounds (48.5%). For acute wounds (33.6%),
traumatic wounds, were the most common type of wound (19.4%)
• Traumatic wounds and pressure ulcers were the most common types of
wounds treated in home care
• Of the total of 310 wounds about half were diagnosed by GPs (47.7%) and
37.4% by the DNs. Together diagnosed GPs and DNs 5.5% of the wounds. 9
patients had no diagnosis
• DNs saw the wound management as their duty and made ​​decisions about
treatment strategies
• The areas of responsibility in wound management for different categories of
staff were not formulated
• Co-operation with GPs was inadequate and consisted mostly of consultation
in case of complications
• Common guidelines for local wound treatment was lacking for most DNs

7. Results, Study II:
• DNs felt responsibility for the care of the patient, and had confidence in
their independent assessments
• DNs considered the patient’s general situation and provided continuity in
care
• Drawing up a wound treatment plan and regular reports were stated as
being important in collaboration with other professionals
• The results included even problems caused by poor organisation and
stress caused by lack of time, lack of treatment rooms and equipment, as
well as difficulties when treating patients in their homes.

8. Results, Study III:
• DNs experienced that their wound care knowledge developed while
treating different types of wounds
• The concrete treatment situation allowed them to confront the problems
involved and reflect on the treatment and care of patients, which in turn
improved their knowledge in wound management and caused them to
develop in the area
• The nurses had different channels for information e.g. colleagues and
dermatology clinic
• The nurses felt that obtaining information from commercial sources was a
good way of obtaining knowledge
• The DNs felt a lack of support and interest from management in trying to
maintain and develop their knowledge and skills in wound care. This was
because of financial obstacles and they felt a lack of time

9. Conclusions
• DNs treat many different types of wounds and take responsibility for
wound management (I, II)
• DNs strive to be practitioners of professional wound care (II) but they are
hindered by organizational factors (I, II, III)
• DNs described the lack of guidelines for wound management (I), and they
expressed dissatisfaction due to inadequate co-operation with GPs (I, II,
III)
• Training in wounds and wound management needs to be strengthened for
both DNs and GPs

10. Further research
• Several studies have shown positive results for wound healing when
introduced interdisciplinary approach. Therefore it is important to study
how to strengthen and improve co-operation between DNs and GPs in
wound management
• Guidelines for wound management are available on the internet and it is
important to study why these are not used